Tadalafil (Adcirca, Alyq)

Tadalafil (Adcirca, Alyq) 

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

• Indicated for the treatment of pulmonary arterial hypertension (PAH) (WHO [World Health Organization] Group 1) to improve exercise ability

Patients must meet the following criteria for the indication(s) above:

• Adcirca®, Alyq™, Revatio® (tablets):
  • Patient has a diagnosis of Pulmonary Arterial Hypertension (WHO Group 1) with class II, III, or IV symptoms confirmed by a specialist (e.g., cardiologist, pulmonologist) (medical record documentation required)
• Revatio® (suspension):
  • Patient has a diagnosis of Pulmonary Arterial Hypertension (WHO Group 1) with class II, III, or IV symptoms confirmed by a specialist (e.g., cardiologist, pulmonologist) (medical record documentation required), AND
  • Patient cannot swallow or has difficulty swallowing tablet formulation, OR
  • Patient requires administration of a dose that cannot be obtained with generic sildenafil 20 mg tablets

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P&T Committee:

• Peripheral vasoconstriction
• Patients taking nitrates
• Erectile dysfunction (ED)
• All non-FDA approved uses not listed in the approved indications

Dosing:

• Adcirca®: 40 mg daily
• Alyq™: 40 mg daily
• Revatio®: 20 mg three times a day

Approval:

• One year